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ASN Wikibase Occurrence # 183083
Last updated: 31 August 2020
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Date:03-JAN-2016
Time:14:30 LT
Type:Silhouette image of generic BE9L model; specific model in this crash may look slightly different
Hawker Beechcraft C-90GTI King Air
Owner/operator:Supermercados Shibata
Registration: PP-LMM
C/n / msn: LJ-1866
Fatalities:Fatalities: 2 / Occupants: 2
Other fatalities:0
Aircraft damage: Written off (damaged beyond repair)
Category:Accident
Location:Paraty, Rio de Janeiro -   Brazil
Phase: Approach
Nature:Passenger - Non-Scheduled/charter/Air Taxi
Departure airport:SBMT
Destination airport:SDTK
Investigating agency: CENIPA
Narrative:
Rescue teams have found the wreckage of a twin turboprop that crashed while atempting to land at Paraty airport (SDTK), in the "Green Coast" of Rio de Janeiro state. Two bodies were found on the crash site, in the woods of Corumbé. Acording to the Aeronautical Accidents Investigation and Prevention Center (CENIPA), the Beech King-Air C-90 GTI, registration PP-LMM, which belongs to Supermecados Shibata (a supermaket chain with several stores in São Paulo), departed Campo de Marte (SBMT), in São Paulo on sunday (3), at 13:34 local time, bound to Paraty with scheduled landing at 14:15, but did not confirmed its landing, nor contacted the tower with information about route changing.

The Fire Department received two phone calls from locals, around 16:00, both describing an aircraft flying over the woods between the districts of Corumbê and Graúna. They told the authorities hearing a bang, an than, not heaering the engine noise from the aircraft. Smoke vestige in the air coming from the woods were photographed by locals in the region and where exchanged through social networks.

Paraty airport informed that an aircraft was flying over the region while the locals reported hearing the bang. Eight firefighters than begun the search in the woods region.

Acording to (Infraero), the aircraft was operated by Táxi Aéreo Aristek, who has an hangar in Campo de Marte/SP. The twin-engine belongs to Supermercado Shibata Ltda., with headquarters in Mogi das Cruzes, in São Paulo, as described in the documents registry from ANAC. On sunday, Marisa Shibata, the supermaket chain director, claims to have no details about the disappearance or on the operation of the aircraft. The responsible for Aristek could not be reached for comment the case.

Contributing factors.
- Attention - undetermined
Moments before the accident, another aircraft successfully completed the landing at the Paraty aerodrome. It is possible that the pilot's attention was focused on this information, which indicated the possibility of landing, despite the critical conditions faced, leading him to take high risks to make the landing in critical conditions.
Also, the presence of a copilot not qualified to operate the aircraft may have influenced the pilot's cognitive processes, causing deconcentration or deviation of attention from the pilot.
- Attitude - contributed.
Recurring attempts to make the landing indicated an excess of self-confidence on the part of the pilot, leading him to continue the flight to the Paraty aerodrome, even in adverse weather conditions.
The bold operational profile of the pilot, his past experience and the rules and values ​​adopted informally in the group of pilots are possible factors that influenced the development of this attitude of excessive self-confidence.
- Adverse weather conditions - contributed.
On the day of the accident, the weather conditions were not favorable for visual flight at the Paraty aerodrome.
- Culture of the working group - contributed.
Among the pilots who operated in the Paraty region, competitive behavior had been installed, valued by the social recognition attributed to those who managed to operate in critical conditions. Above all, landing under conditions
adverse weather conditions in the region was considered a manifestation of proficiency and professional competence. The values ​​shared by that group of pilots favored the weakening of the collective perception about the present operational risks.
The presence of other pilots who were also trying to land in the region on the day of the occurrence, as well as the landing made by one of these aircraft, moments before the accident, and also the accomplishment of two failed attempts of the PP-LMM aircraft, translates clear evidence of that behavior.
- Pilot forgetfulness - undetermined.
The fact that the landing gear was not retracted during the second launch in the air indicated a failure, fueled by the possible forgetfulness of the crew, to perform the planned procedure. Maintaining the landing gear in the lowered position affected the aircraft's performance during the ascent, which may have contributed to the aircraft not reaching the height required to clear obstacles.
- Pilotage Judgment - undetermined.
The possible decision not to retract the landing gear during the launch affected the aircraft's performance during the climb, which may have contributed to the aircraft not reaching the height necessary to clear the obstacles.
- Motivation - undetermined.
The successful landing by the pilot of another aircraft, even under unfavorable conditions, may have increased the motivation of the pilot of the PP-LMM aircraft to complete the landing, in order to demonstrate his proficiency and professional competence.
- Perception - contributed.
The occurrence of a collision with the ground, in controlled flight, indicated that the crew had a low level of situational awareness at the time of the occurrence. This inaccurate perception of the circumstances of the flight made it impossible to adopt the possible measures that could prevent the collision.
- Decision making process - contributed.
The pilot chose to make two landing attempts at the Paraty aerodrome, despite adverse weather conditions, indicating an inaccurate assessment of the risks involved in the operation.
This evaluation process may have been adversely affected by the competition behavior installed among the pilots. In this context, it is possible that the pilot based his decision only on the successful landing of another aircraft, a fact that limited his scope of evaluation.
- Organizational processes - undetermined.
The PP-LMM aircraft was operated by a group of pilots, mostly composed of freelance professionals, who were informally managed by a hired pilot. Therefore, there was no formal system used by the operator to recruit, select, monitor and evaluate the performance of professionals.
The failures related to the management of this process, possibly, caused inadequacies in the selection of pilots, in the crew scale, in untimely activations and, as in the case in question, in the choice of crew member not qualified to exercise function on board.

Sources:

https://gauchazh.clicrbs.com.br/geral/noticia/2016/01/aviao-desaparecido-e-dois-corpos-sao-encontrados-em-paraty-4943719.html
https://www.brasil247.com/pt/247/rio247/211933/Encontrados-destro%C3%A7os-do-avi%C3%A3o-que-caiu-em-Paraty.htm
http://g1.globo.com/sp/mogi-das-cruzes-suzano/noticia/2016/01/aviao-que-caiu-em-paraty-e-de-familia-de-empresarios-de-mogi.html
https://www.em.com.br/app/noticia/nacional/2016/01/04/interna_nacional,721705/encontrados-destrocos-do-bimotor-que-caiu-em-paraty.shtml
http://sistema.cenipa.aer.mil.br/cenipa/paginas/relatorios/rf/pt/PP-LMM_03_01_16_AC.pdf

Accident investigation:
cover
  
Investigating agency: CENIPA
Status: Investigation completed
Duration:
Download report: Final report


Images:



Revision history:

Date/timeContributorUpdates
04-Jan-2016 14:17 caiomp Added
04-Jan-2016 14:57 Black Typhoon Updated [Time, Aircraft type, Operator, Phase, Departure airport, Destination airport]
04-Jan-2016 15:58 Aerossurance Updated [Aircraft type, Source, Narrative]
04-Jan-2016 16:08 Aerossurance Updated [Nature, Source, Narrative]
04-Jan-2016 17:47 dedevillela Updated [Photo, ]
04-Jan-2016 17:47 dedevillela Updated [Source, Narrative, Photo, ]
04-Jan-2016 17:57 dedevillela Updated [Source]
04-Jan-2016 18:37 dedevillela Updated [Departure airport, Destination airport, Narrative]
05-Jan-2016 19:01 Anon. Updated [Narrative]
10-Jan-2016 10:38 cleberjc Updated [Location]
26-Jun-2020 17:18 KagurazakaHanayo Updated [Source, Narrative]
26-Jun-2020 17:56 harro Updated [Narrative, Accident report, ]

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